Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Systematic Review of Prevalence, Risk Factors, and Risk for Metachronous Advanced Neoplasia in Patients With Young-Onset Colorectal Adenoma.

Background & aimsThe incidence and mortality of early-onset colorectal cancer (CRC) are increasing. Adenoma detection, removal, and subsequent endoscopic surveillance might modify risk of CRC diagnosed before age 50 years (early-onset CRC). We conducted a systematic review of young-onset adenoma (YOA) prevalence, associated risk factors, and rate of metachronous advanced neoplasia after YOA diagnosis.MethodsWe performed a systematic search of multiple electronic databases through February 12, 2019 and identified studies of individuals 18 to 49 years old that reported prevalence of adenoma, risk factors for adenoma, and/or risk for metachronous advanced neoplasia. Summary estimates were derived using random effects meta-analysis, when feasible.ResultsThe pooled overall prevalence of YOA was 9.0% (95% CI, 7.1%-11.4%), based on 24 studies comprising 23,142 individuals. On subgroup analysis, the pooled prevalence of YOA from autopsy studies was 3.9% (95% CI, 1.9%-7.6%), whereas the prevalence from colonoscopy studies was 10.7% (95% CI, 8.5%-13.5). Only advancing age was identified as a consistent risk factor for YOA, based on 4 studies comprising 78,880 individuals. Pooled rate of metachronous advanced neoplasia after baseline YOA diagnosis was 6.0% (95% CI, 4.1%-8.6%), based on 3 studies comprising 1493 individuals undergoing follow-up colonoscopy, with only 1 CRC case reported. Overall, few studies reported metachronous advanced neoplasia and no studies evaluated whether routine surveillance colonoscopy decreases risk of CRC.ConclusionsIn a systematic review, we estimated the prevalence of YOA to be 9% and to increase with age. Risk for metachronous advanced neoplasia after YOA diagnosis is estimated to be 6%. More research is needed to understand the prevalence, risk factors, and risk of CRC associated with YOA

The effect of ballooning following carotid stent deployment on hemodynamic stability

ObjectiveWhile patient eligibility for carotid artery stenting (CAS) is well established, the intraoperative technique remains widely varied. The decision to perform poststent ballooning (PSB) is operator-dependent and often influenced by the interpretation of poststent angiography. While visually creating a greater luminal diameter, it is unclear whether PSB has immediate risks or long-term benefits. The purpose of this report is to determine whether PSB has any effects on periprocedural hemodynamic stability.MethodsA retrospective analysis of all patients that underwent CAS between 2005 and 2012 at a tertiary care center was performed. The primary end point was hemodynamic instability, defined as bradycardia (a heart rate of <60 beats/min) or hypotension (systolic blood pressure of <90 mm Hg) during the intraoperative or postoperative period. Binary logistic regression model was performed to determine the effect of PSB on the occurrence of hemodynamic instability, adjusting for patient's age, sex, hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, recent myocardial infarction, previous carotid endarterectomy, high-risk status, and symptomatic status.ResultsA total of 103 (51 men and 52 women) patients underwent placement of a unilateral carotid stent between 2005 and 2012 at our institution. All patients underwent prestent dilatation. However, 70% (n = 72) underwent PSB whereas 30% (n = 31) did not. PSB was a significant predictor of hemodynamic depression (odds ratio [OR], 3.8; 95% confidence interval, 1.3-11; P < .01). Symptomatic status, recent myocardial infarction, hyperlipidemia, and coronary artery disease were associated with a length of stay exceeding 24 hours postoperatively (OR, 6.6; P < .01, OR, 6.1; P < .01, OR, 5.4; P = .04, and OR, 9.3; P < .01, respectively). At follow-up, 97% (83/86) stents were patent. Two stent stenoses occurred in the group that received PSB, while one stent stenosis occurred in the group that did not receive PSB.ConclusionsPSB increases the risk of intra- or postoperative hemodynamic depression in CAS and might increase the risk of major adverse cardiovascular events. Given the added complications and the lack of evidence supporting long term patency, PSB should be only selectively used

National cost of trauma care by payer status

Background: Several studies have described the burden of trauma care, but few have explored the economic burden of trauma inpatient costs from a payer\u27s perspective or highlighted the differences in the average costs per person by payer status. The present study provides a conservative inpatient national trauma cost estimate and describes the variation in average inpatient trauma cost by payer status.Methods: A retrospective analysis of patients who had received trauma care at hospitals in the Nationwide Inpatient Sample from 2005-2010 was conducted. Our sample patients were selected using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify admissions due to traumatic injury. The data were weighted to provide national population estimates, and all cost and charges were converted to 2010 US dollar equivalents. Generalized linear models were used to describe the costs by payer status, adjusting for patient characteristics, such as age, gender, and race, and hospital characteristics, such as location, teaching status, and patient case mix.Results: A total of 2,542,551 patients were eligible for the present study, with the payer status as follows: 672,960 patients (26.47%) with private insurance, 1,244,817 (48.96%) with Medicare, 262,256 (10.31%) with Medicaid, 195,056 (7.67%) with self-pay, 18,506 (0.73%) with no charge, and 150,956 (5.94%) with other types of insurance. The estimated yearly trauma inpatient cost burden was highest for Medicare at $17,551,393,082 (46.79$10,772,025,421 [28.72%]), Medicaid ($3,711,686,012 [9.89$2,831,438,460 [7.55%]), and other payer types ($2,370,187,494 [6.32$274,598,190 (0.73%) for patients who were not charged for their inpatient trauma treatment. Our adjusted national inpatient trauma yearly costs were estimated at $37,511,328,659 US dollars. Privately insured patients had a significantly higher mean cost per person than did the Medicare, Medicaid, self-pay, or no charge patients.Conclusions: The results of the present study have demonstrated that the distribution of trauma burden across payers is significantly different from that of the overall healthcare system and suggest that although the burden of trauma is high, the burden of self-pay or nonreimbursed inpatient services is actually lower than that of overall medical care

National cost of trauma care by payer status

Background: Several studies have described the burden of trauma care, but few have explored the economic burden of trauma inpatient costs from a payer\u27s perspective or highlighted the differences in the average costs per person by payer status. The present study provides a conservative inpatient national trauma cost estimate and describes the variation in average inpatient trauma cost by payer status.Methods: A retrospective analysis of patients who had received trauma care at hospitals in the Nationwide Inpatient Sample from 2005-2010 was conducted. Our sample patients were selected using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify admissions due to traumatic injury. The data were weighted to provide national population estimates, and all cost and charges were converted to 2010 US dollar equivalents. Generalized linear models were used to describe the costs by payer status, adjusting for patient characteristics, such as age, gender, and race, and hospital characteristics, such as location, teaching status, and patient case mix.Results: A total of 2,542,551 patients were eligible for the present study, with the payer status as follows: 672,960 patients (26.47%) with private insurance, 1,244,817 (48.96%) with Medicare, 262,256 (10.31%) with Medicaid, 195,056 (7.67%) with self-pay, 18,506 (0.73%) with no charge, and 150,956 (5.94%) with other types of insurance. The estimated yearly trauma inpatient cost burden was highest for Medicare at $17,551,393,082 (46.79$10,772,025,421 [28.72%]), Medicaid ($3,711,686,012 [9.89$2,831,438,460 [7.55%]), and other payer types ($2,370,187,494 [6.32$274,598,190 (0.73%) for patients who were not charged for their inpatient trauma treatment. Our adjusted national inpatient trauma yearly costs were estimated at $37,511,328,659 US dollars. Privately insured patients had a significantly higher mean cost per person than did the Medicare, Medicaid, self-pay, or no charge patients.Conclusions: The results of the present study have demonstrated that the distribution of trauma burden across payers is significantly different from that of the overall healthcare system and suggest that although the burden of trauma is high, the burden of self-pay or nonreimbursed inpatient services is actually lower than that of overall medical care